Chapter 32 Common Assessment Abnormalities (objective #5)

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Distended neck veins

distention greater than 3cm with pt sitting at a 30-45 degree angle.- Possible etiology is elevated right atrial pressure; right sided heart failure.

Central Cyanosis

Bluish or purplish tinge to areas such as tongue, conjunctivae, inner surface of lips.- Inadequate O2 saturation of arterial blood due to pulmonary or cardiac disorders.

Peripheral Cyanosis

Bluish or purplish tinge in extremities, or in nose and ears.- Reduced blood flow because of heart failure, vasoconstriction, cold environment.

Splinter Hemorrhages

small red to black streaks under finger nails.- Infective endocarditis .

Clubbing of nail beds

obliteration of normal angle between base of nail and skin.-Endocarditis, congenital defects, prolonged O2 deficiency.

Color changes in extremities with postural change

Pallor, cyanosis, mottling of skin after limb elevation; dependent rubor (reddish-blue discoloration), glossy skin.- Chronic decreased arterial perfusion.

Ulcers

Venous- necrotic crater-like lesion usually found on lower leg. Characterized by slow wound healing. Arterial- pale ischemic base, well defined edges, usually found on toes, heels, lateral malleoli.

Varicose Veins

Visable dilated, discolored, tortuous vessels in lower extremities. - Incompetent valves in vein.

Bounding pulse

sharp, brisk, pounding pulse. - hyperkinetic states, anemia, hyperthyroidism.

Thready pulse

Weak, slowly rising pulse; easily obliterated by pressure. - Blood loss, decreased CO, aortic valve disease, peripheral arterial disease.

Irregular pulse

regularly or irregularly; skipped beats. - Cardiac dysrhythmias.

Pulsus alternans

Regular rhythm but strength of pulse varies with each beat.- Heart failure, cardiac tamponade.

Absent pulse

lack of pulse. - atherosclerosis, trauma, embolus.

Thrill

vibration of vessel or chest wall.- Aneurysm, aortic regurgitation, arteriovenous fistula.

Rigidity

Stiffness or inflexibility of vessel wall.- Atherosclerosis.

>100 bpm

tachycardia.- Exercise, anxiety, shock, need for increased cardiac output, hyperthyroidism.

<60 bpm

bradycardia. - Rest/sleeping, SA or AV node damage, athletic conditioning, side effect of drugs, hypothyroidism.

Displaced point of maximal impulse

palpated below the 5th intercostal space and left of the midline. -Left ventricluar dilation.

Unusually warm extremities

Hands or feet. - possible thyrotoxicosis.

Cold extremities

Hands/feet cold to touch. -Intermittent claudication, peripheral arterial obstruction, low CO, severe anemia.

Pitting edema of lower extremities or sacral area

visable indentation after application of firm pressure; weight gain; tightening of clothing. - Interruption of venous return to heart, fluid in tissues.

Abnormal capillary refill

blanching of nail bed for >2sec after application of firm pressure is released.- Possible reduced arterial capillary perfusion, anemia.

Asymmetry in limb circumference

Measureable swelling in limb. -Venous thromboembolism, varicose veins, lymphedema.

Abnormal Cardiac Borders

left border of cardiac dullness extends past MCL in 5th ICS; border of cardiac dullness extends past sternal border. - Cardiac enlargement due to coronary heart disease, heart failure, cardiomyopathy.

Pulse deficit

apical HR exceeds the peripheral pulse rate.- Cardiac dysrhythmias; most commonly atrial fibrillation.

Arterial Bruit

Turbulant flow sound in peripheral artery.- Arterial obstruction or aneurysm.

Third Heart Sound

Extra heart sound, low pitched, heard in early diastole, similar to the sound of a gallop. -Left ventricular failure; volume overload; mitral, tricuspid or aortic regurgitation; HTN.

Fourth Heart Sound

Extra heart sound, low pitched, heard in late diastole, similar to the sound of a gallop. -Forceful artrial contraction from resistance to ventricular filling.

Cardiac Murmurs

Turbulent sounds occuring between normal heart sounds; characterized by loudness, pitch, shape, quality, duration and timing.- Cardiac valve disorder, abnormal blood flow patterens.

Pericardial friction rub

High-pitched, scratchy sound heard during S1 and/or S2 at the apex; heard best with pt sitting or leaning forward, at the end of expiration. -Pericarditis.

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